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Hip Osteoarthritis
From WikiSM
Other Names
- Osteoarthritis of the Hip
- Hip OA
- DJD of the Hip
- Degenerative Joint Disease of the Hip
Background
- This page refers to Hip Osteoarthritis (Hip OA)
History
Epidemiology
- Prevalence
- Jordan et al: symptomatic hip OA was reported at 9.2% among adults age 45 years and older, with 27% of the study population having radiographic evidence of disease[1]
- Men have higher prevalence before age 50, women have higher prevalence after age 50
- Highest in Caucasians (3-6%), estimated to be <1% in Asians, blacks, East Indians, or native Americans[2]
- Incidence
- Estimated at 88 per 100,000 person years (need citation)
- CDC: Lifetime risk for symptomatic hip OA is 18.5% (men), 28.6% (women)[3]
Pathophysiology
Etiology
- Primary OA
- Accounts for majority of hip OA
- Idiopathic process
- Not characterized by inflammatory process, rise in systemic inflammatory markers
- Combination of genetic, age-related changes, mechanical stress and biomechanical factors
- Secondary OA
- Previous trauma or fracture
- Congenital malalignment
- Inflammatory process such as Septic Arthritis, Paget Disease of the Bone
- Neuropathic joint disease
- History of recurrent Corticosteroid Injections
- Endocrinopathies including Cushings Disease, Hemochromatosis
- Degenerative process
- Characterized by progress loss of articular cartilage, mismatch between damage and repair
- Cartilage damage occurs as a combination of biomechanical forces, biochemical factors
- Subsequent reactive bone formation, osteophyte growth, bone remodeling
- Para-articular tissues also involved
- Hip OA results as a constellation of all these factors
Associated Conditions
- Hip Fracture
- Hip Dislocation
- Femoroacetabular Impingement[4]
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis
- Hip Dysplasia
Pathoanatomy
- Hip Joint
- Defined by the articulation of the head of the Femur and the Acetabulum
- Hyaline Cartilage
- Composed of chondrocytes embedded in extracellular matrix
- Extracellular matrix composed of proteoglycans, including aggrecan, type II collagen
Risk Factors
- General
- Occupation
- Muscle weakness
- History of
- Hip trauma including Hip Fracture, Hip Dislocation
- Hip Dysplasia[9]
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis
Differential Diagnosis
- Fractures And Dislocations
- Arthropathies
- Muscle and Tendon Injuries
- Bursopathies
- Ligament Injuries
- Neuropathies
- Other
- Pediatric Pathology
- Transient Synovitis of the Hip
- Developmental Dysplasia of the Hip (DDH)
- Legg-Calve-Perthes Disease
- Slipped Capital Femoral Epiphysis (SCFE)
- Avulsion Fractures of the Ilium (Iliac Crest, ASIS, AIIS)
- Ischial Tuberostiy Avulsion Fracture
- Avulsion Fractures of the Trochanters (Greater, Lesser)
- Apophysitis of the Ilium (Iliac Crest, ASIS, AIIS)
Clinical Features
- History
- Patient course is most commonly insidious, worsening over time
- Pain is in the hip or groin
- Worse in the morning or after long periods of rest
- Stiffness, which is often transient
- Movement and activities that mobilize the joint may provide relief
- Ask patient "do you have trouble putting on socks and shoes"?
- Physical Exam: Physical Exam Hip
- May see restriction and pain with internal and external rotation
- Limited extension, flexion, internal rotation
- Special tests
- FADIR Test: Flexion, adduction, internal rotation
- FABER Test: Flexion, abduction, external rotation
- Straight Leg Test: Negative
Evaluation
Radiographs
- Standard Radiographs Hip
- Findings
- Joint space narrowing, which can be obliterated in end-stage disease
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
- Deformity of femoral head, acetabulum
- Helpful to trend radiographs over time to monitor disease progression[10]
- Altman et al: most sensitive diagnostic criteria is hip pain with two of the following[11]
- ESR <20 mm/hr (not routinely tested)
- Femoral or acetabular osteophytes
- Joint space narrowing
CT
- Not required for diagnosis
- May be indicated for pre-op planning or to exclude other etiologies
- Helpful to get a better sense of bone structures and articular surface
MRI
- Not required for diagnosis
- May be indicated for pre-op planning or to exclude other etiologies
- Helpful to evaluate the Acetabular Labrum, periarticular strucctures
Laboratory Evaluation
- Generally not indicated unless secondary cause is implicated
- Takahash et al: correlation between serum pyridinoline and tissue inhibitor of metalloproteinases 1 (TIMP-1) levels and the severity of OA assessed by the KL System[12]
- Not commercially available but suggest future diagnostic and prognostic markers
Classification
Kellgren-Lawrence Classification
- Grade 1[13]
- Doubtful OA with possible joint space narrowing medially
- Subtle osteophyte formation around the femoral head
- Grade 2
- Mild OA with definite joint space narrowing inferiorly
- Definite osteophyte formation, slight subchondral sclerosis
- Grade 3
- Moderate OA with marked narrowing of the joint space
- Small osteophytes, some sclerosis and cyst formation
- Deformity of the femoral head and acetabulum
- Grade 4
- Obliterated joint space with features seen in grades 1 to 3, large osteophytes
- Gross deformity of the femoral head and acetabulum
Tonnis Classification
- Grade 0
- Normal radiographs
- Grade 1
- Sclerosis of femoral head and acetabulum
- Slight joint space narrowing
- Slight lipping at joint margins
- Grade 2
- Small cysts in femoral head/acetabulum
- Moderate joint space narrowing
- Moderate loss of head sphericity
- Grade 3
- Large cysts in femoral head/acetabulum
- Joint space obliteration/severe narrowing
- Severe femoral head deformity vs. AVN
Management
Prognosis
Nonoperative
General
- Patient Education
- Helping patient understand disease process, empower them in their own care
- Shown to decrease pain, improve quality of life in patients affected by OA[14]
- Physical Exercise
- Low-impact exercise is associated with reduction in pain[15]
- Consider water-based or aquatic exercise therapy, which is also beneficial with less weight bearing[16]
- Avoid exercises/ activities that provoke pain such as twisting, high impact sports (running)
- Promote low impact activities such as yoga, cycling, swimming
- Promote improved flexibility, stretching and range of motion
- Physical Therapy
- First line therapy for mild-moderate hip OA[17]
- In patients with moderate-severe disease, PT is much less likely to be helpful
- Weight Reduction
- 10 lbs of weight gain is equivalent to 60 lbs of stress on the joint[18]
- Weight loss is associated with reduction in cartilage loss, joint impact
- Foot wear
- Patients should be educated, encouraged to wear shoes with good shock absorbance, arch support
- Assist Devices should be considered including
- Walking sticks
- Tap turners
- Walking cane
- Rolling walker
Pharmacologic Therapies
- Acetaminophen
- Literature is not great for acetaminophen[19], often used in conjunction with NSAIDS
- NSAIDS
- Consider oral, topical
- Capsaicin
- Limited use due to joint depth
- Opioids
- Indicated in refractory cases, not first line therapy
- Glucosamine, Chondroitin
- Some benefit in reducing pain, no beneficial effects on function from knee OA literature
- Evidence is underwhelming[20]
- Needs to be updated/ researched
Modalities
- Transcutaneus Electrical Nerve Stimulation
- Consider as an adjunct, need update on evidence
Joint Injections
- Corticosteroid Injection
- Offer short term pain relief, inferior to hyaluronic acid at 6 months[21]
- Can be helpful diagnostically if etiology of pain is unclear
- Hyaluronic Acid
- Prolotherapy
- Platelet Rich Plasma
Operative
- Indications
- Severe/ Kellgren grade 4
- Refractory to conservative measures
- Technique
- Total Hip Arthroplasty (THA)
- Hip Resurfacing
- Arthroscopic Debridement (controversial)
- Osteotomy
- Femoral head resection
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Needs to be updated
Complications
- Increased fall risk[22]
- Chronic pain
- Loss of function
- Inability to return to work or sport
See Also
- Internal
- External
- Sports Medicine Review Hip Pain: https://www.sportsmedreview.com/by-joint/hip/
References
- ↑ Jordan JM, Helmick CG, Renner JB, et al. Prevalence of hip symptoms and radiographic and symptomatic hip osteoarthritis in African Americans and Caucasians: the Johnston County Osteoarthritis Project. J Rheumatol. 2009;36(4):809-815.
- ↑ 2.0 2.1 Brandt, Kenneth D., Paul Dieppe, and Eric L. Radin. "Etiopathogenesis of osteoarthritis." Rheumatic Disease Clinics of North America 34.3 (2008): 531-559.
- ↑ Murphy NJ, Eyles JP, Hunter DJ. Hip osteoarthritis: Etiopathogenesis and implications for management. Adv Ther. 2016 Nov;33(11):1921–46. DOI:
- ↑ Ganz, R, Leunig, M, Leunig-Ganz, K, Harris, WH. The etiology of osteoarthritis of the hip. Clin Orthop Relat Res. 2008;466(2):264-272.
- ↑ Felson DT. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev. 1988;10:1–28. DOI:
- ↑ MacGregor AJ, Antoniades L, Matson M, Andrew T, Spector TD. The genetic contribution to radiographic hip osteoarthritis in women: Results of a classic twin study. Arthritis Rheum. 2000 Nov;43(11):2410–6. DOI:
- ↑ Harris EC, Coggon D. Hip osteoarthritis and work. Best Pract Res Clin Rheumatol. 2015 Jun;29(3):462–82.
- ↑ Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former élite male athletes. BMJ. 1994 Jan 22;308(6923):231–4. DOI: https://doi.org/10.1136/bmj.308.6923.231. Erratum in: BMJ 1994 Mar 26;308(6932):819.
- ↑ Lanyon P, Muir K, Doherty S, Doherty M. Assessment of a genetic contribution to osteoarthritis of the hip: Sibling study. BMJ. 2000 Nov 11;321(7270):1179–83. DOI:
- ↑ Reijman M, Hazes JM, Pols HA, et al. Role of radiography in predicting progression of osteoarthritis of the hip: prospective cohort study. BMJ 2005;330:1183.
- ↑ Altman R, Alarcón G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991;34:505-14.
- ↑ Takahashi M, Naito K, Abe M, et al. Relationship between radiographic grading of osteoarthritis and the biochemical markers for arthritis in knee osteoarthritis. Arthritis Res Ther 2004;6:R208-12.
- ↑ Kellgren J. The Epidemiology of Chronic Rheumatism. Vol. 2. Oxford: Blackwell Scientific; 1963. Atlas of standard radiographs in arthritis.
- ↑ Hochberg MC, Altman RD, Brandt KD, et al. Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip.American College of Rheumatology. Arthritis Rheum 1995;38:1535-40.
- ↑ Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev. 2014 Apr 22;(4):CD007912. DOI:
- ↑ Bartels E, Juhl C, Christensen R, Hagen K, Danneskiold-Samsøe B, Dagfinrud H, Lund H. Aquatic exercise for the treatment of knee and hip osteoarthritis. 2016 Mar 23;3:CD005523. DOI:
- ↑ Zhang W, Doherty M, Arden N, et al. EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) EULAR evidence based recommendations for the management of hip osteoarthritis: Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT) Ann Rheum Dis. 2005 May;64(5):669–81.
- ↑ Reyes C, Leyland KM, Peat G, Cooper C, Arden NK, Prieto-Alhambra D. Association between overweight and obesity and risk of clinically diagnosed knee, hip, and hand osteoarthritis: A population-based cohort study. Arthritis Rheumatol. 2016 Aug;68(8):1869–75.
- ↑ Ennis, Zandra Nymand, et al. "Acetaminophen for chronic pain: a systematic review on efficacy." Basic & clinical pharmacology & toxicology 118.3 (2016): 184-189.
- ↑ Wandel S, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. (2010)
- ↑ He, Wei-wei, et al. "Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis." International Journal of Surgery 39 (2017): 95-103.
- ↑ ] S.G. Leveille, J. Bean, K. Bandeen-Roche, R. Jones, M. Hochberg, J.M. Guralnik, Musculoskeletal pain and risk for falls in older disabled women living in the community, J. Am. Geriatr. Soc. 50 (2002) 671–678.
Created by:
John Kiel on 5 July 2019 08:33:10
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Last edited:
5 October 2022 13:05:44
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